Siesta

Hello all! Will be taking a break from Cuccurullo for the rest of January in order to study for SAE's. I'll be back in February with Rheumatology.

Nonorganic back pain

What are Waddell's signs?

Answers:
3 or more Waddell's signs are cause for suspicion. DO ReST:

1. Distraction: Normal seated straight leg raise.
2. Overreaction: exaggerated reaction to exam.
3. Regionalization: Motor/sensory abnormalities without an anatomic basis.
4. Simulation: Pain axial load on skull.
5. Tenderness: Exaggerated sensitivity or dramatic pain with light touch.

Infection of the spine

*1. What are risk factors for vertebral body osteomyelitis and discitis?
*2. What are the most common infectious agents?
3. What diagnostic studies are used for spine infection?
4. What is the treatment of spine infection?

Answers:
1. Age, diabetes, immunodeficiency, penetrating trauma, GU procedures, invasive spinal procedures, intravenous drug abuse (incr cervical risk), TB (thoracolumbar jxn).
2. Staph aureus (most common), pseudomonas (IV drugs), TB (Pott's disease).
3. By 2 wks, X-ray shows disc space narrowing and blurred endplates. MRI most sensitive: T1 hypointensity, T2 hyperintensity, gadolineum enhancing. Leukocytosis, increased ESR, CRP, positive bone bx.
4. Conservative care icludes spinal immobilization and antibiotics with early ambulation. Surgical care includes decompression or fusion.

Soft tissue spine disorders

1. What is the presentation of lumbosacral strain?
2. What are causes of lumbosacral strain?
3. What is myofascial pain syndrome?
4. How does myofascial pain present?
5. What is the treatment of myofascial pain?

Answers:
1. Muscle ache with spasm and guarding, can occur up to 24-48 hours after injury. Normal neuro exam.
2. Overuse, excessive eccentric contraction, accel-decel injuries, acute trauma.
3. Regional pain with local muscle tenderness and trigger points.
4. Muscle tenderness, trigger points, paresthesias, poor sleep, fatigue, normal neuro exam.
5. Correction of underlying causes, analgesics, tricyclics, rehab focusing on flexibility, strengthening and aerobic exercises. Trigger point injections. Psych counseling.

Sacroiliac jt disorders

*1. What is the sacroiliac jt and what is its innervation?
2. What is the clinical presentation of SI jt pain?
3. What are provocative tests of the SI jt?
4. What studies are used to assess the SI jt?

Answers:
1. The SI jt is the articulation between the sacrum and ilium with a synovial jt anterior and syndesmosis posterior. Innervation is L5 dorsal ramus and lateral S1-S3 dorsal rami.
2. Acute or gradual back, buttock, leg, or groin pain, discomfort with associated muscles.
3. FABER test, Gaenslen test, iliac compression test (SI jt pain with downward force on iliac crest), Yeoman's test (SI jt pain with hip ext and ilium rotation), Gillet test (normal is that PSIS rotates down with raising leg 90 deg), Seated flexion test (monitor PSIS while pt bends forward).
4. X-ray, bone scan, CT, MRI. Fluoroscopic SI jt injxn may have higher diagnostic value.

Facet syndrome

1. What are facet joints?
2. What is the etiology of facet syndrome?
3. What is the presentation of facet syndrome?
4. How is facet syndrome diagnosed?
5. What is the treatment of facet syndrome?

Answers:
1. These are true synovial joints containing a capsule, meniscus, and synovial membrane.
2. Somatic dysfunction, positional overload, capsular tears, meniscus/synovial impingement, spondylosis.
3. Neck or back pain, worse rotation and extension. Referred pain to neck may be nondermatomal. No neuro abnormalities.
4. Imaging with X-ray (degen changes), CT, MRI (hypertrophy of capsule and facets).
5. Relative rest, NSAIDs. Rehab focusing on lumbar spine stabilization with flexion and neutral postures. Interventional procedures including facet jt injections or dorsal rami medial branch ablation.

Compression fractures

1. What make up the anterior, middle, and posterior columns of the spine? Which ones lead to instability with compression fractures?
2. Where do compression fractures of the spine usually occur?
3. What factors contribute to compression fractures?
4. What is the clinical presentation?
5. How are compression fractures diagnosed?
6. What is the treatment?

Answers:
1. Anterior (stable): ALL, ant 2/3 of vertebral body. Middle (unstable): PLL and post 1/3 of vertebral body. Posterior (stable): Lig flavum, supra and infraspinous ligs, posterior elements (pedicles, facets, spinous process).
2. Thoracolumbar junction.
3. Trauma, osteoporosis, osteomalacia, medications (steroids), neoplasm.
4. Sudden onset of constant thoracolumbar pain, exacerbated by valsalva, turning in bed, incidental trauma.
5. X-rays (vertebral body wedging), bone scan with SPECT, CT, MRI.
6. If <25%>50% vertebral height decr, instability, or kyphotic deformity causing neurologic compromise.